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 Fever without focus  

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A 65 year old man got his femur fractured (Intertrochanteric) in a road side accident.Dynamic Hip screw fixation was done. One pint of blood was infused during the operation.He was given Ceftriaxone before the operation. And after the operation combination of Ceftriaxone and Amikacin was given. He was discharged after 4 days and was advised to use ciprofloxacin for 8 days.On returning home he started having fever temp. was normal in the morning but 101 F in the evening.Wound inspection did not reveal any sign and was normal.A thorough history was taken and surprisingly there was no other complaint.
Physical exam. was normal except for mild pallor.
Routine Lab tests showed high ESR 87
Hb 10 all other tests were normal including LFTs Serum creatinine and x-ray chest and x-ray of the operated femur.Pt has lost appetite and is dec. his wt. He was well before the accident. N/O diabetes. HTN. Smoking

Q1 What is your prime concern about this pt?

Q2 What is the most likely cause of the fever?

Q3 What organism(s) is involved?

Q What further investgations should be done?


It sound like Osteomyelitis ..X-ray was normal maybe because it was done early(xray can be normal during the first week).
The most likly involved organism is S.aureus.
I think bone scan should be done as further investigation.Although Bone biopsy is the best choice ,it would be better to avoid it in this acute case when the diagnosis can be made by history ,xray and bone scan.



i think any body who had suggested the antibiotic before and after surgery is not familiar with the organisms this pt is risk for or don't know the antibiotic coverage of the abx he had prescribe.(poor gram positive coverage)

i should add blood cs,

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